When uninsured immigrants fail to pay their bills, the University Medical Center in Tucson, Ariz., might just report them to the Department of Homeland Security.

Michael S. Victoroff, MD

The folks at University Medical Center in Tucson, Ariz., have come up with an interesting strategy to reduce financial losses from uncompensated care. Their idea is to report to the Department of Homeland Security all uninsured immigrants — legal and illegal, as well as other foreign nationals — who fail to pay their bills.

Ethical analysis of this plan involves asking how it squares with applicable principles, and then, what good or bad might arise from implementing it. To put this idea in perspective, let's note that University Medical Center is said to oppose the sterner measure proposed in the U.S. House by Rep. Dana Rohrbacher (R-Calif.), which would require hospitals to fingerprint and photograph all illegal immigrants and provide their addresses and employers' names to the Department of Homeland Security.

So-called uncompensated care includes at least three ethically distinct categories. They are charity (when individuals are not able to pay), fraud (when individuals are not inclined to pay, including scammers and thieves), and denials of coverage (where contractual terms limit payment). How ever it's divided up, uncompensated care costs U.S. hospitals a lot of money. This expense becomes added, like a tax, to the fees hospitals charge for "compensated care."

To move things along, I'm going to ignore the messy tangential issue of how much operating profit hospitals legitimately "need," and simply stipulate the necessity for hospitals to surcharge those who pay to make up for those who don't. Nothing else would make sense.

So, let no one imagine that we don't have national health insurance! Of course we do. It just operates informally, parallel to the health services market. People who don't pay are cared for with money siphoned from other cash flows — chiefly insurance. As the debate meanders about whether to restructure this process through an explicit public system, this private "taxation" continues.

From the standpoint of principles, we have to ask UMC, "How does ratting out immigrants serve the goals of medicine?" Normally, privacy rights may be balanced against the protection of the patient, another individual, or the community at large. For example, I wouldn't blink to learn that the hospital calls the police when a gunshot victim arrives, and I bet they also report cases of hanta virus to the health department. Thus, if a patient, another person, or the community were at risk of harm from immigrant nonpayment, whistleblowing could be justified. The problem is, except for economic harm, I don't see how this could be.

Important distinction

Another principle that might apply is that the hospital — the operations part, as opposed to the health delivery part — by revealing patient names and addresses, would not violate medical privacy since it doesn't propose to send health records to the Department of Homeland Security, but only financial ones. This distinction recognizes the dual aspects of health care, which commingles a moral, physician-patient covenant with a legal, vendor-payer contract. We do allow physicians and hospitals to send patients to collections, even if it causes bankruptcy and financial devastation.

The problem with this analysis is the potentially opposing tenet of the AMA Code of Ethics (7.01) that forbids physicians to withhold medical records as hostages to unpaid fees. In that situation, physician/creditors must put the patient's medical well being ahead of their own financial interests. If this is a correct analogy, a policy that threatens social harm to patients (conceivably substantial) to coerce payment might be improper. The difference between threatening medical harm (which is impermissible), as opposed to financial or social harm (which is OK), seems blurry.

Forget immigrants for a minute. What if the hospital used nonmedical information about other patients to extort payment? For instance, suppose the hospital announced it would talk to spouses about circumstances that were suspicious for adultery — but only if the bill was in default? How about if the hospital reported expired drivers' licenses to the DMV? (Or, booted cars in the parking lot?) How about reporting marijuana traces on clothing to the DEA? Addresses to creditors? Health care workers often discover valuable bits of social intelligence in the course of treatment. How do the general rules of privacy change when payment is at stake?

"Dangerous territory"

The UMC policy is not outrageous, in principle, but it does represent a wedge poking into dangerous territory. All health workers have dual responsibilities to patients and to the law. Final judgment about adding immigration duties depends on the utilitarian analysis. What are the foreseeable effects of using Homeland Security as a collection agency? Even if such a policy can be justified in general ethical terms, will its benefits be worth the trouble it causes?

Here I am skeptical. Anyone can predict that threatening illegals with the attention of the U.S. Citizenship and Immigration Services (formerly INS, now a bureau of the DHS) will deter them from coming to the hospital.

In the short term, this will almost certainly reduce "uncompensated care." Perhaps some will see this as an incentive to pay (among those who can). My guess is that they are the minority. Perhaps some will even see this as a reason not to be an illegal alien?

The short-term benefit of making the hospital a "dangerous" place for illegal immigrants is that they will tend to stay away, but there is good evidence that reducing access to care increases disease within the local community. The poster child for delayed care would be a septic infant, whose parents are intimidated from taking their baby to the ER.

Incapable of paying

Granted, the UMC plan is not as drastic as Rep. Rohrabacher's House bill. But on a milder scale, it points the same way. It attaches the surprise, "Gosh, this not only costs money (which I can deal with by disappearing), but is a potential exposure point if my documents aren't in order." It is hard to imagine that most immigrants fall into the category of "able to pay, but disinclined." I'm sure some of these exist, but my guess is that the majority of the uninsured are incapable of paying cash for major services.

So, rather than a "collection incentive," what is being proposed is financial razor wire that will partition many of America's hospitals from all but the very sickest immigrants. Maybe I'm missing critical data, but the INS threat smells like a scapegoating tactic, gratifying to hospital boards frustrated by an unfair social burden, but without practical benefits to justify its wider effects.

Our culture provides fire and police protection to everyone — even foreign visitors — irrespective of citizenship or ability to pay. Can we imagine some wacky libertarian society in which the 911 operator's first question is, "Will that be cash, check, or charge?" (Actually, I can, but I wouldn't want to live on that planet.)

"Uncompensated care" is an issue for the public safety professions, but they are injured less by it, because their compensation model is different from that of health care. One could say, "You can't just walk into a supermarket and haul off a load of product without paying. What lets you do that in a hospital?" Very true, and properly so, but at least our society has enough grocery safety nets to make starvation rare. Granted, it's easier to buy somebody a meal than a liver transplant, but health care safety nets exist (even if they are not always well designed or funded).

Perhaps Arizona is so victimized by nonpaying immigrants that driving them off makes good sense. But I worry that, instead of scaring them away, UMC's plan might just scare them to death.

Michael S. Victoroff, MD, is a family practitioner in Denver who has also been an HMO medical director.

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